We need more studies to find out how common this is for children with autism and gender dysphoria.

In addition, we need studies to look at how persistence and desistence from gender dysphoria work for children with autism. Is the developmental process different from neurotypical children? How should parents, educators, and therapists work with children who have both autism and gender dsyphoria?

As the authors say, “Careful long-term clinical observation and further studies are needed.”

More details on the boy’s gender dysphoria:

[The boy came to the clinic at age 5 for behaviors related to autism] At the age of 7, he verbalized a strong aversion to being a boy and desired to be a girl. The boy behaved as if he were a girl and preferred to play with girls. Based on his clinical symptoms that lasted more than 6 months, the comorbid diagnosis of GID was made according to ICD-10 criteria.

After entering school, he exhibited behaviors such as using stationery with Disney princesses and dressing himself in clothes with flowers. He rarely went to the bathroom because he did not want to be seen urinating in a standing position. He skipped swimming classes at school to avoid exposing his chest. Only at his home, the boy wore skirts and makeup. At school, he was bullied by classmates because of his feminine behaviors. However, as school teachers were supportive and intervened appropriately, he never refused to attend school.*”

“At the age of 11, when puberty started, he became confused and repeatedly shaved his body hair. He tried to keep his voice tone high. However, as puberty progressed his gender dysphoria gradually alleviated.

In Japan, in general, junior high school students are required to wear school uniforms based on their biological sex, typically a skirt for girls and trousers for boys. They are also requested to obey school regulations related to length of hair, though the strictness is highly school-dependent. Our patient entered a public school in his residential district and had to behave as a typical male student. As a consequence, his gender-related manifestations fell below the threshold for the diagnosis of GID as of age 16 (the time of this writing).”

Note: This is not just a question of changes in behavior – the authors also say that his gender dysphoria gradually alleviated as he went through puberty. In addition, the authors got informed written consent before publishing this study.

*School refusal is a significant problem for students with gender dysphoria in Japan. (Bullying seems to be a problem everywhere.)

“At the age of 8 years, B had started to claim that she was a boy. She refused to wear girls clothing and jewelery. B corrected persons if she was being addressed as ‘she’ and used her brothers’ shaving machine. At twelve years of age, B refused to visit the girls toilet but was forbidden by the parents to use the boys toilet. She has now been told to use the one and only gender neutral toilet in the school.”

And, at follow up:*

“She refuses to wear women’s clothes or to appear in swimsuit on the beach. Moreover, she claims that she is a boy, although she has discontinued the habit of correcting peers for addressing her ‘her’.”

The authors discuss three possible ways to interpret her symptoms of gender dysphoria and the implications for treatment.

First they suggest that the gender dysphoria could be part of the autism, specifically a “ritualized and obsessive-compulsive behavior of a kind which is commonly seen in autistic syndromes.”

The authors suggest that autism makes social and sexual relationships difficult, although people with autism are attracted to others. The expression of these feeling may be unusual. “A minority of people with autism display a variety of paraphilic behaviour, e.g., exhibitionism, voyeurism and fetishism, and the desire for a beloved person may find expression in an obsessive manner.”

Gender dysphoria then might be “a paraphilic consequence of the impairment in social interaction” due to her autism. In that case the proper response would be “similar to the one employed when encountering other sexual manifestations with autistic people: a gradual firm correcting of the behavior in the direction of gender concordant behavior, but without anger or distress.”

The authors do not discuss the possibility that the gender dysphoria could be part of the autism in some other, non-sexual way. They should have.

Second, they suggest that the gender dysphoria might be seen as an obsessive-compulsive disorder and separate from the autism. In that case the proper treatment would be clomipramine.

There have been cases where patients with obsessional gender dysphoria were successfully treated with lithium carbonate, but the symptoms were different from the ones in this case.**

More importantly, in this case, treatment with clomipramine relieved the symptoms of OCD and mutism, but not the gender dysphoria. In fact, her symptoms of gender dysphoria increased, although it may be that they only became more apparent – for one thing she was talking more.

Third, they suggest that the gender dysphoria could be viewed as a disorder on its own and not a symptom of autism or OCD. In that case, the proper approach would be to treat both the autism and the gender dysphoria. When the teenager was of age,*** she would then be eligible for sex reassignment surgery.

They caution that “this patient suffers from a putative risk factor (autism), which has to be seriously considered before any intervention can be performed. “

As with other case studies, this is about one person. We can only draw limited conclusions from it.

It does show, however, that a person with autism can have symptoms of gender dysphoria. Further, in this case, the symptoms were probably not caused by OCD, as treatment for OCD did not relieve her gender dysphoria.

We could use further research to determine the relationship between gender dysphoria and autism and the best way to treat children and teenagers who have both.

While many of the intersections of autistic and female in my life have been social, there are undeniable physical intersections too.

The arrival of adolescence brought with it hints of what it would mean to be an autistic adult. My first real meltdowns. My first experience with depression. My first confusing encounters with physical intimacy.

With nothing to compare those experiences to, I assumed they were a normal part of being a teenager. Everyone said that being a teenager was hard. I couldn’t dispute that. It didn’t seem necessary to look beyond the explanation of “this is hard for everyone.”

That would become a theme. Pregnancy. Breastfeeding. Postpartum depression. My body’s reaction to birth control pills. Countless books and magazine articles assured me that these things were no walk in the park. Not knowing that I was autistic…

There was joy in that realization and also sadness. My diagnosis came too late to help me in my role as a mother when my daughter was young, a role that I often struggled with. Many aspects of being autistic can make the child-rearing years of motherhood challenging.

Babies have round-the-clock needs. They’re stressful, messy, unpredictable and demanding. Basically they are everything that an autistic person finds hard to cope with. Gone was my precious alone time. Gone were my carefully crafted routines. Even my body was no longer my own, transformed first by pregnancy then by postpartum hormones and breastfeeding.

I was completely unprepared for how hard motherhood would be. Unaware that I was autistic, I often felt like a bad mom. What kind of mother breaks down sobbing uncontrollably and bangs her head against the dining room wall? Certainly none that I was aware…

Note: This is my contribution to the Ultraviolet Voices anthology. It’s nearly 5000 words long, so I’m going to serialize it here over the next 3 weeks.

At five, I wanted to be a boy. I don’t know what I thought being a boy meant. Maybe I thought it meant playing outside in the summer, shirtless and barefoot. Maybe I thought it meant not wearing dresses.

The author discusses the “extreme male brain” theory of autism and suggests some alternatives.

She also talks about factors that might influence how people with autism spectrum disorders experience gender:

“This raises the question of what role being autistic might play in the formation of our personal experience of gender. For example, autistic children are less sensitive to social cues than typical children and may not make friends with or become part of groups of same-gender peers. If we’re not tuned in to what the social norms for children of our gender are, we’re less likely to adopt them early in life.

There may also be an aspect of autistic-related body dysmorphia in general that factors into gender dysphoria for some autistic individuals. Many autistic people have difficulty feeling connected to their physical selves or being physically comfortable with their body.

Finally, there is the issue of sensory sensitivities. Dressing or presenting androgynously may be a result of gender dysphoria or it may be related to avoiding sensory triggers associated with certain types, textures or styles of clothing.”

The experts do not know yet what caused the autism or how to cure it. They have just shown that about 10% of kids can overcome it.

Factors that increase the chance of outgrowing autism include: earlier parental concern, earlier referral to therapists, and earlier and more intense intervention. Applied Behavior Analysis (ABA) may increase the chances of a good outcome. (ABA is not appropriate therapy for gender dysphoria; there is a famous case of it being used with a gender non-conforming boy with disastrous results.)

In addition, children who start with better scores on IQ tests are more likely to do well. Presumably their autism is not as severe to start with.

The children who overcome autism may still have some symptoms, including “social awkwardness, attention deficit hyperactivity disorder, repetitive movement, mild perseverative interests and subtle difficulties in explaining cause and effect.” One of the people interviewed in the article also mentions sensory issues such as feeling that omelets are slimy or disliking the texture of paper.

However, for the group of children whose autism faded, we can’t be sure if their brains changed due to treatment, if their brains changed on their own, or if their brains were never the same as the brains of other children with autism,

Another study found that therapy could change the brain activity of children with autism.

According to the New York Times, “Prior studies determined that autistic children show more brain engagement when they look at color photos of toys than at color photos of women’s faces — even if the photo is of the child’s mother. Typically developing children show the reverse, and the parts of their brain responsible for language and social interaction are more developed than those of autistic children.”

Toddlers who received “25 hours a week of a behavioral therapy designed to increase social engagement” had brain patterns like typically developing children after two years; toddler who received the regular community intervention did not.

This article is not directly related to gender dysphoria, but it is an interesting look at a condition that may be somehow linked to gender dysphoria.